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NOTE: PULL ALL PE, ITS (SEPTIC, WELL, ETCAWIAKE COPIES FOR FILE <br /> I. SEWAGE: <br /> Distance to Public Sewers: ,If/ Connection necessary: Yes No <br /> Does exist septic system comply with San Joaquin County Development Title X549 ? <br /> Yes No Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> 2. WATER SUPPLY: <br /> Is water supplied by private well: Yes ',t—"�No Is well proper: Yes No <br /> State deficiency: <br /> Is well system a Public Water system? Yes No Is the permit current? Yes No <br /> Does existing or proposed use make this well Public Water: Yes No Is water/well <br /> sampling current: yes No Additional information or comments: <br /> 3. GARBAGE & REFUSE: <br /> Licensed scavenger pick-up: Yes No Service Area No.: Other proposed <br /> disposal method: 1NeR,42( ' <br /> Potentia problem(s): - <br /> 4. FLY, MOSQUITO OR VECTOR POTENTIAL: 1 - - �/lQC� <br /> State possible vector potential and necessary control: efi <br /> fir, <br /> 5. TOILETBATH FACILITIES: <br /> Number and locations existing: Additional <br /> facilities needed: <br /> 6. PREVIOUS OPERATION HISTORY: <br /> 7. GENERAL SANITATION: <br /> State any problems not previously noted: <br /> S. POPULATION DENSITY: <br /> Approximate number of people per square mile: <br /> Elf 06 06 Rev 1/99 <br />